Escolar Documentos
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e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 14, Issue 8 Ver. II (Aug. 2015), PP 64-95
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Abstract :In view of increasing number of penetrating thoracic or abdominal or combined injuries, this study
has been chosen with reference to the patients presenting at Civil Hospitals Ahmedabad, affiliated with B.J.
Medical college.This is a study of 25 cases. Age/Sex Incidence, Common viscera involved depending on site
involved, operative procedures to be carried out according to viscera involved, Complications related to
procedure and injuries, common cause of death have been highlighted in this study.
Keywords: Penetrating injuries to thorax, penetrating abdominal injuries, common cause of death in
penetrating trauma, Complications related to penetrating trauma.
1.
INTRODUCTION
Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years
and is the third most common cause of death regardless of age. Penetrating thoracic or abdominal or combined
injuries are one of the common injuries caused by assault. These injuries are associated with high risk of life
threatening intra abdominal or intra thoracic organ injury. Due to the inadequate treatment of the injuries, many
of the cases are fatal. The knowledge in the management of Penetrating trauma is progressively increasing due
to the in-patient data gathered from different parts of the world.
INDEX
1)
2)
3)
4)
a.
b.
c.
d.
e.
5)
6)
7)
8)
9)
Table of contents
Aims and objectives of study
Materials and methods / Data Collection
Review of literature
Historical aspects
Aetiology and mechanism of injury
Clinical features
Diagnosis and investigations
Management
Observation and discussion
Summary
Conclusion
References
Acknowledgements
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2. Aims Of Study
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4. Review of literature
a.) Historical aspects
Injury to the Abdomen and thorax has always been considered as one of the most critical injuries
inflicted upon the body. The historical documentation of abdomino-thoracic trauma is probably as old as history
itself.
The oldest medical and scientific document known is the Edwin Smith Surgical Papyrus. This is
thought to be an undated version of documents prepared by Imhotep around 3000 BC. Greek soldiers in the
Trojan War, in the 1st century AD, were removed from the battle field and looked after in certain barracks or
ships which seemed to be the earliest trauma centres. Valetudinaria had been established along the frontiers of
the Roman Empire to treat legionaries who had suffered trauma.
Physicians were referred to by the Ionian Greeks as "In Ipos" meaning an "Extractors of arrows"
(Loria, 1948). Xenophon in his Anabasis speaks of a Greek army captain who returned to his camp literally
holding his bowels in his hands after an eviscerating wound of the abdomen. From the Homeric epics, we learn
of the death of Polydorus at the hands of Achilles whose weapon on entering the back of the victim protruded
out in front thereby leaving the boy "bending with his bowels clasped in his hands". Eurymachus succumbed to
the effects of a liver wound which was inflicted by an arrow from powerful bow of Odysseus.Hippocrates (460355 BC) recognized the high incidence of mortality ensuing from intra-abdominal and intra-thoracic injuries,
and postulated that `A severe wound of the bladder, small intestine, stomach, and the liver is deadly' (Adams
1886). Several of the twenty three stab wounds inflicted on the person of Julius Caesar were situated in the
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Fig. 1 and 2 Penetrating injury with evisceration of bowel & Multiple stab wound over abdomen
(2)
Distension of abdomen:Increasing abdominal distention indicates continuous hemorrhage, content spillage or gaseous distention
due to perforation of hollow viscera. So the repeated measurement of abdominal girth is very important along
with vital parameters if patient is managed conservatively.
(4)
Protrusion of viscera from wound:This symptom is present in many cases of penetrating abdominal and trauma. Mostly small bowel
protrusion occurs from the wound site.
(5)
Vomiting:It is usually due to peritonitis or central in origin, if there is associated head injury. Hematemesis suggests
bleeding in upper g.i. tract.
(6)
Hematuria:Frank hematuria suggests major urinary tract injury, while retention suggests urethral or urinary bladder
injury. In case of retention of urine, neurological examination is necessary to rule out spinal cord injury.
Blood at tip of external meatus suggests urethral injury.
(7)
Bleeding per rectum:Bleeding per rectum or blood in stool suggests possibility of some intestinal injury. If blood is bright red
in colour, then it is from lower intestinal tract like sigmoid colon or rectum. If it is brown to black in colour then
it is from upper g.i. tract.
(8)
Associated injuries:It may be in form of head injury, chest injury with multiple rib fractures, major bone fractures of
extremities, spine or other injuries. All these associated injuries should be assessed and treated accordingly.
(9)
Breathlessness:Patients with thoracic injury present with complaints of breathlessness. Symptom may be due to collected
hemothorax, pneumothorax, pain. Cardiac injury should be kept in mind depending on site of injury.
Signs
(1)
General:Altered level of consciousness in a case of penetrating injury is usually due to:a)
Blood loss.
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Head injury.
Consumption of alcohol or drugs before the accident should be kept in mind.
(2)
Vital data:Cold extremities, tachycardia, tachypnea, hypotension and severe pallor suggests ongoing blood loss.
Examination findings
Local per abdominal examination :
Pattern of respiration
Respiratory rate
Tracheal shift
Palpation:Tenderness
Subcutaneous emphysema
Bruit
Percussion:-
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Auscultation:Respiratory sounds :
Systemic examination:Rapid general examination is mandatory in all the cases. More is missed by not looking than by not knowing.
Neurological evaluation and distal neurovascular evaluation in case of fractures should be done.
d.) Diagnosis And Investigation[1,2,3,6,7]
Laboratory
Hb-PCV :
It will show the amount of blood loss. Decreasing haematocrit value indicates persistent blood loss.
Renal Function Test:
It will show the status of kidney. Prerenal ARF may be seen in patient with severe blood loss.
Liver Function Test:
In case of billiary tract injury and liver parenchymal injury, Liver function test may be altered.
Serum amylase :
Elevated level suggests pancreatic or bowel injury, but it is not a very sensitive test as, it is also increases in
other conditions.
Conditions like pancreatitis, choledocolithiasis, etc.
Serum transaminase :
Elevated level suggests hepatic injury.
Urine Examination :
Presence of RBC suggests urinary tract injury.
Diagnostic Peritoneal Lavage :[6,14]
It is controversial. Risk vs Benefit ratio should be considered in mind. It was first described in 1960. Introducing
peritoneal dialysis catheter through infraumbilicalincision, and about 1 litre of normal saline is run into
peritoneal cavity (in children 10-15 ml/kg). Then patient is rolled from side to side. Returning fluid is collected
and sent for investigation.
It is positive if :1
2
3
4
5
Blood in catheter
Fluid studies revealing RBC more than 1,00,000m/m3 indicate solid organ injury.
WBC more than 500m/m3 indicate peritonitis a late feature of trauma.
Amylase more than 175 IU/d1 is suggestive of pancreatic injury.
Fluid should also be examined for presence of faecal material, bile etc.
Radiological
1.
Plain X-Rays :[15]
Plain X-rays of abdomen supine and standing :
Free gas under diaphragm suggestive perforation of hollow viscera.
In some cases even in perforation of hollow viscera free gas under diaphragm may not be seen.
Ground glass appearance suggests free fluid.
Air bubbles in right upper quadrant just medial to kidney suggest retroperitoneal duodenal injury.
Elevation or abnormality of diaphragm will suggest collection under the diaphragm.
Plain X-Ray of Chest :
It will show rib fracture, hemothorax, pneumothorax or both. It will also show an elevated diaphragm or with
abdominal viscera or Ryles tube in case of rupture of diaphragm.
2.
Ultrasound : [3,6]
Most frequently used investigation now-a-days. It detects intraperitonial and retroperitoneal collection of fluid,
solid organ injury with surrounding hematoma.
Disadvantages :Lower sensitivity for free fluid <500 ml.
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Perihepatic&hepato-renal space
Perisplenic
Pelvis
Pericardium
3.
CT Scan:[3,6]
Now-a-days the role of CT Scan is very much increasing because of its accuracy. It has very much use in
thoracic injuries. It is also useful investigation in evaluation of retroperitoneal structures like kidneys and
pancreas. It quantitates free fluid, gas and defines severity and staging of solid organ injury and identifies breech
in bowel continuity. Accuracy from 92% to 98%. In case of urinary tract injury, CT IVU has virtually replaced
conventional IVU. It provides better details on anatomy and function.
CT scan is done in selected patients depending upon clinical examination.
Indications :
Penetrating injury with a projectile
Persistent high ICD output
Haemodynamic stability
Duodenal or pancreatic trauma
Normal or unreliable physical examination
Contraindications :
Haemodynamic instability
Allergy to contrast media
Advantage :
Quick assessment
Noninvasive
Reteroperitoneum well assessed
Renal perfusion assessed
Disadvantage :
Non availability at different centres
Higher cost
Hollow viscus injuries
Radiation exposure
Angiography :
Selective catheterization of cardiac, mesenteric and renal vessels done to reveal site of bleeding. It may be
helpful in case of pelvic fracture with ongoing bleeding and reteroperitoneal extension.
Indication :Polytrauma with suspected vascular injury.
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Operative
(1) Diagnostic Laparoscopy :[3,6]
In a hemodynamically stable patient with no signs of peritonitis. One can think of this management option to
look for internal organ injury and in this way patient can be saved from unnecessary laparotomy.
Indication :Penetrating injury with peritoneal breech and no signs of peritonitis.
Disadvantage :Unavailability
Require expertise and set up
Small perforations may be missed
e.) Management
Thoracic Trauma[1,3,6,22]
Penetrating chest trauma deals with two major vital organs lungs and heart. It also includes major vessels aorta,
vena cava and pulmonary vessels.
Penetrating chest trauma can be divided in to Central Chest trauma and Lateral Chest Wall trauma.
Heart and Mediastinum [1,3,22]
It mainly occurs due to Central Chest trauma between nipple lines Xiphisternum to clavicles.
Mostly bullet injury causes this type of injury. Knife seldom penetrates sternum. So penetrating injury caused by
projectile weapons causes this injury. Necessary to assess trajectory of projectile clinically soot present in track.
If possible simple CXR can be done. Management described below
A)
B)
Lungs and Pleural cavity [1,3,22]
Lateral Chest wall injury (Lateral to nipple lines) mainly by short knives causes lung or pleural cavity injury. A
projectile weapon with clearly defined entry and exit wounds with trajectory in lateral chest causes such injury.
Management includes
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Fig 3. Right Lateral Chest injury - Stab wound over right 10 th Intercostal space
Fig 4.ICD insertion in case of chestwall trauma with abdominal drain for laparotomy
Abdominal Trauma
A)
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II
III
IV
V
VI
TYPE OF INJURY
DESCRIPTION OF INJURY
Hematoma
Laceration
Hematoma
Laceration
Hematoma
Laceration
Laceration
Laceration
Parenchymal disruption involving > 75% hepatic lobe or > 3 Couinaud segments (with one
lobe).
Vascular
Vascular
Hepatic avulsion
CT Grading :[3,18]
GRADE
TYPE OF INJURY
DESCRIPTION OF INJURY
Hematoma
Laceration
Capsular avulsion
Superficial lacertion(s) (< 1 cm deep)
Hematoma
Central/subcapsularhaematoma(s) 13cm.
Laceration
Hematoma
Central/subcapsularhaematoma(s) >3cm
III
Laceration
IV
Hematoma
Vascular
Vascular
II
IV
Grade I and II : Most blunt and penetrating hepatic injuries are grade I and II (70% to 90%) and can be
managed with simple techniques (e.g., electrocautery, simple suture, or hemostatic agents).
Grade III : Major intraparenchymal injuries with active bleeding can best be manged by figure fracturing
the hepatic parenchyma and ligating or repairing lacerated blood vessels and bile ducts under direct
vision.
Grade IV : extensive intraparenchymal injuries with major rapid blood loss require occlusion of portal
triad to control hemorrhage.
Advanced technique of repair (III & IV) are performed with Pringle maneuver in place
Extensive hepatorrhaphy
Perihepatic packing
Spleen [2,3,6,12,18]
The spleen is involved in patients who have suffered penetrating abdominal trauma over epigastrium
and left hypochondrium, projectile injury can affect from other quadrants. Impact from both front and back can
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II
III
IV
TYPE OF INJURY
DESCRIPTION OF INJURY
Hematoma
Subcapsularhaematoma< 1 cm.
Laceration
Capsular avulsion,
superficial laceration(s)
Hematoma
Central/Subcapsularhaematoma(s) < 3 cm
Laceration
Hematoma
Laceration
Fragmentation
Devascularisation
Grade of injury:-[2,3,6,18]
TYPE OF
INJURY
DESCRIPTION OF INJURY
Hematoma
Laceration
Hematoma
Laceration
Hematoma
Laceration
IV
Laceration
Laceration
Vascular
GRADE
I
II
III
In hemodynamically stable, adult patients with grade I or II injury can often be treated nonoperatively
If the patient is not hemodynamically stable, operative treatment is required. The operative therapy of
choice is splenic conservation where possible to avoid the risk of death from overwhelming
postsplenectomy sepsis that can occur after splenectomy for trauma. However, in the presence of multiple
injuries or critical instability, splenectomy is more rapid and judicious.
Nonbleeding grade I splenic injury may require no further treatment. Topical hemostatic agents, an argon
beam coagulator, or electrocautery may suffice.
Grade II to III splenic injury may require the aforementioned interventions, suture repair, or mesh wrap of
capsular defects. Suture repair in adults often requires Teflon pledgets to avoid tearing of the splenic
capsule
Grade IV to V splenic injury may require anatomic resection, including ligation of the lobar artery
Kidney[2,3,6,15,18]
The kidney is often involved in penetrating abdominal injuries by impact from behind, and in front in
lumbar region.
GRADE
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Contusion
Hematoma
II
Laceration
<1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation.
III
Laceration
>1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation.
Laceration
Parenchymal laceration extending through renal cortex, medulla and collecting system
Vascular
Laceration
Vascular
IV
Ct grading :[3,6,18]
Categories of renal injuries :
1. Renal contusion or bruising of the renal parenchyma, Microscopic haematuria is common but gross
haematuria can occur rarely.
2. Renal parenchymal laceration into renal cortex. Peri renal haematoma is usually small.
3. Renal parenchymal laceration extending through the cortex and into renal medulla.
4. Renal parenchymal laceration extending into renal collecting system, also, main renal artery thrombosis
from blunt trauma, segmental renal vein or both; or artery injury with contained bleeding.
5. Multiple grade 4 parenchymal lacerations, renal pedicle avulsion, or both; main renal vein or artery injury
from penetrating trauma.
Management of renal injury:[3,19,20]
Nonoperative treatment of renal trauma (grades I to III) has become standard. If the injury is properly
staged, nonoperative management is successful for contusions, contained lacerations, most lesions with
moderate extravasation of urine, or when blood is seen in hemodynamically stable patients.
In the stable patient, obtaining proximal vascular control before unroofing the perirenal hematoma may be
helpful.
Repair of the renal parenchyma, with or without heminephrectomy, can have excellent results.
Reinforcement of the repair with omentum or mesh can be a useful alternative. Wide drainage is indicated.
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DESCRIPTION OF INJURY
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II
III
IV
V
OF
DESCRIPTION OF INJURY
Hematoma
Laceration
Hematoma
Laceration
Laceration
Laceration
Laceration
Grade I :Pancreatic contusion or capsular laceration without ductal injury wide drainage is required. Do
not repair capsular lacerations; this can produce a pseudocyst. The operative goal is to develop a controlled
pancreatic fistula postoperatively, which will generally close spontaneously.
Grade II :Pancreatic transection distal to the SMA , distal pancreatectomy can be done. Attempt splenic
conservation in the stable patient.
Grade III : For Pancreatic transection to the right of the SMA (not involving the ampulla), there is no
optimal operation. The options include wide drainage of the area of injury to develop a controlled
pancreatic fistula; ligation of both ends of the distal duct and wide drainage; and oversewing the proximal
pancreas and performing a Roux-en-Y jejunostomy to the distal pancreas (indicated uncommonly).
Grade IV :Severe injury to both the head of the pancreas and the duodenum may require
pancreaticoduodenectomy.
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Fig
6 Penetrating injury causing Renal
trauma as seen during laparotomy
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B)
Stomach[2,3,6,21]
It commonly occurs in penetrating injury over epigastrium in full stomach patients. Stomach is commonly
involved because of its size and accesibility. Rupture usually occurs along body part, pylorus where it is most
accessible.
Stomach Injury Grading :-[2,3,6]
Grade
I
II
III
IV
V
Description of injury
Contusion or hematoma
Partial thickness laceration
Laceration on GE junction or pylorus <2 cm
In proximal 1/3 of stomach <5 cm
In distal 2/3 of stomach <10 cm
Laceration on GE junction or pylorus >2 cm
In proximal 1/3 of stomach 5 cm
In distal 2/3 of stomach 10 cm
Tissue loss or devascularisation<2/3 of stomach
Tissue loss or devascularisation>2/3 of stomach
AIS-90
2
2
3
3
3
3
3
3
4
4
Management:
Debride and repair the stomach in two layers with silk 2-0,1-0 with or without live or dead omentopexy.
Gastric resection is rarely required. Irrigate and remove gastric contents from the peritoneal cavity.
Pyloroplasty may be required to avoid stenosis, or, rarely resection and esophagogastrostomy are
necessary for gastroesophageal junction injuries
Duodenum[2,3,6,21]
It is infrequently involved organ in penetrating injury over epigastrium and rthypochondrium.
Duodenal Injury Grading :-[2,3,6]
GRADE
I
II
TYPE
INJURY
OF
DESCRIPTION OF INJURY
Hematoma
Laceration
Hematoma
Laceration
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GRADE
TYPE
INJURY
III
Laceration
Laceration
Disruption >75% of the circumference of D2 and involving the ampulla or distal common
bile duct.
Laceration
Vascular
IV
V
OF
DESCRIPTION OF INJURY
Management:
Extensive duodenal injuries require one of the patch and bypass procedures like :
Tube duodenostomy
Retrograde jejunostomy
TYPE OF INJURY
DESCRIPTION OF INJURY
Hematoma
Laceration
II
Laceration
III
Laceration
IV
Laceration
Laceration
Vascular
Devascularised segment.
Laceration
II
Laceration
III
Laceration
IV
Laceration
Transection of colon.
Laceration
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Devascularised segment.
Imbricate antimesenteric wall hematomas with serosal injuries with Lembert stitches to reduce the risk of
delayed perforation.
Injuries to the mesentery of the small bowel, which can bleed massively, must be rapidly controlled.
Colon :
The conventional treatment for colonic injury involves exteriorization or repair with a proximal
diverting colostomy.Current operative options include primary repair of the injury, resection and anastomosis,
and colostomy.
Rectum :
Injuries to the rectum should be defined as intraperitoneal rectum or extraperitoneal rectal injuries.
Often, intraperitoneal rectal injuries can be primarily repaired.
Treat extraperitoneal rectal tears by diverting sigmoid colostomy.
Other procedures include Hartmann resection with end colostomy, end colostomy with a mucus fistula, or
loop colostomy with a stapled distal end.
Gall Bladder and Common Bile duct[3,6,19,21]
Gall bladder and bile duct injury grading:- [19,21]
GRADE TYPE OF INJURY DESCRIPTION OF INJURY
I
Hematoma
II
Laceration
Partial avulsion of gall bladder from liver bed, cystic duct intact.
Laceration or perforation of gall bladder.
III
Laceration
Complete avulsion of gall bladder from liver bed, Cystic duct laceration.
IV
Laceration
Laceration
Management:(a)
Gall bladder injury :
It is uncommon kind of injury. Deep RHC and Epigastric impact leads to
this type of injury. Cholecystectomy is procedure of choice.
(b) Common bile duct injury :
Partial or minor injuries involving less than 50% of circumference are treated by primary repair and T
tube placement.
Major injury or complete transection are treated with choledochoenteric anastomosis.
Urinary Bladder[15,16]
It is injured particularly when distended. Bladder perforations may be either extraperitoneal or
intraperitoneal. Extraperitoneal rupture is usually associated with pelvic bone fracture. Intraperitoneal rupture
occurs when there is blow on dome of bladder when it is full.
Urinary Bladder Injury Grade:-[15,16,21]
GRADE
TYPE OF INJURY
DESCRIPTION OF INJURY
Hematoma
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Partial thickness.
II
Laceration
III
Laceration
IV
Laceration
Laceration
Intraperitoneal or extraperitoneal bladder wal laceration extending into bladder neck or ureteral
orifice ( trigone).
Management :
Intraperitoneal bladder rupture requires exploratory laparotomy and repair.
Repair should be done in multiple layers, absorbable watertight sutures, bladder drainage
Small extraperitoneal bladder ruptures can be managed with bladder drainage alone, but tears with
marked extravasation usually are repaired.
A suprapubic tube is placed if the patient is going to remain supine, whereas a urinary catheter may be all
that is necessary for the mobile patient.
Retroperitoneal Injury[2,3]
Reteroperitonealhaemaetoma occurs at five sites.
1.
Midline suprarenal
Due to disruption of small
2.
Midline infrarenal
branches of aorta or/and IVC
3.
Portal
4.
Lateral perirenal, usually renal injury is the cause.
5.
Pelvic : Loss of blood injuries to deep pelvic arteries and veins.
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Present study
(n=25)
01
02
21-30
13
31-40
05
41-50
03
51-60
01
>60
00
Total
25
Percentage
04
08
52
20
12
04
00
100
In present study 01 (04%) patient less than 10 years, 02 (08%) were from 11 to 20 years,13 (52% ) were from 21
to 30 years,05 (20%) were from 31 to 40 years, 03 (12%) were from 51 to 60 years, 01(04%) from 51 to 60
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Present study
(n=25)
24
01
25
Percentage
96
04
100
Male
Female
96%
In present study there were 24(96%) male and 01(4%) female with a ratio of 24:1.
Ari Leppaniemi, JarmoSalo and ReijoHaapiainen (1995) reviewed 172 cases of penetrating chest and abdominal
trauma 144 (83.73%) cases were male and 28 (16.27%) cases were female with ratio of 5.14:1.
Penetrating abdominal injury: A tertiary care hospital experience by AnisUzZaman, Muhammad Iqbal,
FarhanZaheer, Rehan Abbas Khan, Khalid Ahsan Malik. This study included 79 patients with abdominal trauma
who presented in the Accident and Emergency department of Civil hospital Karachi and underwent exploratory
laparotomy from October 2011 to April 2013. A proforma was used to document patients demography, findings
and final outcome 76 (96.2%) patients were male and 3 patients were female. Results found similar to my study.
Penetrating Chest Trauma In North Of Jordan: A Prospective Study by M Khammash, F El Rabee published in
The Internet Journal of Thoracic and Cardiovascular Surgery Volume 8 Number 1 during the year 2004, 26
patients were managed, 25 males and one female
With results comparable to my study.
The penetrating thoracic and abdominal trauma is more common in age group 21-40 years (n=18,72%) with
male predominance (M:F:24:1) as they are economically productive, more active, and more liable to undergo
rage and homicidal attempts and sustain injuries.
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Present study
(n=25)
19
02
04
Percentage
76
08
16
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25
100
0
Homicide
Suicide
Accident
Present study
(n=25)
21
3
1
25
Abdominal
Thoracic
Abdomino-thoracic
Total
Percentage
84
12
4
100
Thoracic
Abdomino-thoracic
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Percentage
88
52
24
24
72
4
12
60
32
16
20
In my study 22 (88%) patients presented with abdominal pain and 5(20%) patients had history of evisceration of
bowel,6 (24%) patients had vomiting,15(60%) patients had history of bleeding from local site, 13 (52%) patients
presented with abdominal distension, 6(24%) patients were in hypotension and 18 (76%) patients had
tachycardia at the time of presentation, 8 (32%) patients had associated chest pain and breathlessness while
1(04%) patient had history of unconsciousness.
When patient presents with abdominal pain with features of shock (tachycardia, hypotension), it should
arouse the suspicion of active intra-abdominal bleeding and immediate evaluation and treatment should be
started. Patients with evisceration of bowel loop should be generously examined and should be taken to OT as
soon as possible due to risk of strangulation and prevent changes of peritonitis. Hematuria in a patient with
penetrating abdominal trauma suggests injury to kidney, ureter, bladder or urethra and should be managed
accordingly. In a penetrating thoracic and abdominothoracic trauma patient with the complain of chest pain and
breathlessness thorough evaluation should be done to rule out hemothorax, pheumothorax, hemopneumothorax,
lung contusion, subcutaneous emphysema, pericardial effusion, cardiac tamponade . Vomiting or history of
LOC are indicators of probable head injury in the patient of trauma and should be managed accordingly. Results
were comparable to other studies.
Number out of 25
6
1
1
Percentage
24
4
4
In my study 6 (24%) patients presented with associated CLW, 1 patient had tendon rupture and 1 had head
injury.
CLW is seen mostly on arms indicating sign of defending himself from penetrating trauma and head injury is
post syncope from penetrating trauma.
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Number out of 25
5
2
1
Percentage
20
8
4
In my study 5(20%) patients had anemia on presentation which may be due to blood loss or pre-existing condition. 1 had
some psychiatric illness who presented with suicide and 2 patients had history of some surgery in past.
Number out of 25
18
6
1
Percentage
72
36
4
In my study 18(72%) patients had single entry wound, 6(36%) patients had 2-5 entry wounds and 1 patient had
more than 5 wounds on presentation.
o
Number out of 25
20
4
1
Percentage
80
16
4
My study showed 20(80%) patients had acute angle wound centring midline, 4(16%) patients had direct right
angle entry wound and 1 patient had obtuse angle.
This states that wound impacted were most of the times directed towards centre.
Number out of 25
9
4
1
3
3
4
1
3
2
4
0
Percentage
36
16
04
12
12
20
04
12
08
16
0
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Number out of 25
6
1
2
1
2
1
2
1
1
4
Percentage
24
4
8
4
8
4
4
4
4
16
Organ involvement
7
6
5
4
3
2
1
0
In my study 6(24%) patients had jejunal injuries, followed by tranverse colon, Liver and Kidney 2(8%) cases
each.
All thoracic injury were associated with lung parenchymal injuries as all of them were lateral chest wall injuries.
No cases were associated with major thoracic vessel and heart.
J.E. Pridgen and A.F. Heriff (1967) reviewed 776 cases of penetrating abdominal wounds and found colonic
injuries in 15.33%, gall bladder rupture in 2.9% and mesenteric injuries in 3.47% of cases. Vascular injuries,
involving aorta were present in 0.5% and iliac vein in 0.64% cases. The other injuries include- 2.57% bladder
injuries, 4.12% pancreatic injuries, 13.14% stomach injuries, 22.8% liver injuries and 21.26% small bowel
injuries. Thus results were found comparable.
Results comparable to study Penetrating abdominal injury: A tertiary care hospital experience by AnisUzZaman,
Muhammad Iqbal, FarhanZaheer, Rehan Abbas Khan, Khalid Ahsan Malik, where Intra-abdominal injuries,
included liver (n = 14, 17.7%), spleen (n = 12, 15.2%), kidney (n = 4, 5.1%), pancreas (n = 4, 5.1%), stomach (n
= 12, 15.2%), small bowel (n = 34, 43%) and large bowel (n = 35, 44.3%).
Penetrating chest injuries: analysis of 99 cases by lk YAZICI, Alkn YAZICIOLU, Ertan AYDIN, Koray
AYDODU, Sadi KAYA, Nurettin KARAOLANOLU The study retrospectively reviewed the records of 99
patients presenting to our hospital with penetrating chest trauma during the previous 4 years (April 2007to June
2011) from all over Ankara, the capital of the Republic of Turkey. The group comprised 90 male (90.9%) and 9
female (9.1%) patients, with a mean age of 29.0 years. Of these patients, 62 (62.6%) had left -sided, 33 (33.3%)
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In my study as depicted by table jejunum followed by transverse colon was most commonly affected organ in
umbilical region, epigastrium was associated with injury in liver followed by stomach, lumbar and iliac region
were associated with kidney and ureter injuries.
Results comparable to study Penetrating abdominal injury: A tertiary care hospital experience by AnisUzZaman,
Muhammad Iqbal, FarhanZaheer, Rehan Abbas Khan, Khalid AhsanMalik,Most entry wounds were found on
ventral abdominal wall (57%), involving the right upper quadrant in majority (31.6%) of patients where Intraabdominal injuries, included liver (n = 14, 17.7%), spleen (n = 12, 15.2%), kidney (n = 4, 5.1%), pancreas (n =
4, 5.1%), stomach (n = 12, 15.2%), small bowel (n = 34, 43%) and large bowel (n = 35, 44.3%).
Penetrating chest injuries: analysis of 99 cases by lk YAZICI, Alkn YAZICIOLU, Ertan AYDIN, Koray
AYDODU, Sadi KAYA, Nurettin KARAOLANOLU The study retrospectively reviewed the records of 99
patients presenting to our hospital with penetrating chest trauma during the previous 4 years (April 2007to June
2011) from all over Ankara, the capital of the Republic of Turkey. The group comprised 90 male (90.9%) and 9
female (9.1%) patients, with a mean age of 29.0 years. Of these patients, 62 (62.6%) had left -sided, 33 (33.3%)
had right-sided, and 4 (4%) had central penetrating injury . Results were comparable to my study.
Number of cases
5
2
Ureteral injury
Gastric Perforation
Retroperitoneal Hematoma
Hemoperitoneum (Anterior abdominal wall
bleeding)
Lateral chest wall trauma
ICD output < 1500 ml stat output
1
1
1
7
Procedure done
Primary closure of perforation
Resection and anastomosis of affected
segment
Resection and anastomosis of affected
segment
Closure (hepatorrhaphy) and Abgel
packing
Primary repair (renorrhaphy) and abgel
packing
Primary repair and DJ stenting
Primary repair
Lavage and Closure
Drainage and Lavage
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2
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In present study most common peroperative finding was hemoperitoneum which was treated by drainage and
lavage, followed by jejunal perforation (single) treated by primary repair, then followed by multiple small bowel
perforation treated by resection anastamosis of affected segment, tranverse colon, liver and kidney came next in
incidence which were repaired primarily.
In thoracic injury out of 4 cases 3 were managed conservatively by ICD insertion and monitoring, 1
thoracotomy was done which showed internal mammary artery tear, which was ligated and ICD insertion was
done.
Results were comparable to study Penetrating abdominal injury: A tertiary care hospital experience by
AnisUzZaman, Muhammad Iqbal, FarhanZaheer, Rehan Abbas Khan, KhalidAhsan Malik, where small bowel
perforation were commonly found followed by large bowel and liver.
Penetrating chest injuries: analysis of 99 cases by lk YAZICI, Alkn YAZICIOLU, Ertan AYDIN, Koray
AYDODU, Sadi KAYA, Nurettin KARAOLANOLU The study retrospectively reviewed the records of 99
patients presenting to our hospital with penetrating chest trauma during the previous 4 years (April 2007to June
2011) from all over Ankara, the capital of the Republic of Turkey.Intercostal tube thoracostomy was the only
therapy required in 68 patients (68.7%), whereas 21 patients (21.2%) had conservative management and only 10
patients (10.1%) underwent thoracotomy and exploration.Conclusion: In this study we emphasize that chest tube
thoracostomy should remain by far the most common and appropriate method of treating penetrating injury to
the thorax. Results were comparable.
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Drain
on day
6
70ml/day
50ml/day
70ml/day
30ml/day
100ml/day
5
5
3
3
100ml/day
7
6
5
4
3
2
1
0
removal
In present study it was found that average drain output was 70ml/day for small bowel perforation and patient
started oral feeding on POD 5, removal day of drain was averaging sixth day after starting orally, for
hemoperitoneum alone drainage average drain output 30ml/day, patient started oral feeding on POD 3 and drain
removed on 5th day, Liver parenchymal injury was associated with high drain output averaging 100ml/day, oral
feeds allowed from 2nd post op day and drain removal on 5th day. Renal parenchymal injuries were associated
with high drain output and patient started orally on 3rd day.
Results were comparable to study Penetrating abdominal injury: A tertiary care hospital experience by
AnisUzZaman, Muhammad Iqbal, FarhanZaheer, Rehan Abbas Khan, Khalid Ahsan Malik, where average drain
period and output were found similar.
In present study 25 cases of penetrating thoracic and abdominal trauma has been studied and following are the
relevant observations and discussions:
For Thoracotomy
Procedure done
Thoracotomy and internal
mammary artery ligation
Drain
on day
-
removal
For thoracotomy average ICD output per day was 100ml/day till the patient had ICD tube. ICD tube was not
removed so no data on removal day found. Patient died with ICD in situ.
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SSI
Seroma
Dehicence of wound
Pneumonia
6(24%)
4(16%)
1(4%)
4(16%)
in
Number of complications in
study by AnizZaman (n=79)
30.6 %
12.8%
6.3 %
-
and
Number of complications in
study by AnizZaman (n=79)
-
7
6
5
SSI
Seroma
Dehicence of wound
Pneumonia
Incisional hernia
Diaphragmatic hernia
1
0
Number Of such morbidity/ complication
Most common complication found was SSI (Surgical Site Infection) accounting for 6(24%) cases followed by
seroma and pneumonia accounting for 4 (16%) cases each. The reason of this observation appears to be related
to surgery performed in category 3 and 4 where there is gross peritoneal contamination with bile and fecal
material. Also all surgeries were performed in emergency so there was no adequate bowel preparartion and
optimization of pre operative factors affecting wound management like diabetes, hypoprotenemia, anaemia etc.
Thus this all factors flare up the wound infection rate. Post Operative ventilator associated pneumonia and chest
infection in post op stay account for pneumonia.
Incisional hernia and Diaphragmatic hernia were reported complications. Incisional hernia was present in
patient with wound dehiscence in follow up and diaphragamatic hernia was found in patient with thoracic stab
injury who presented with complication at 1 year follow up.
Results were comparable to study Penetrating abdominal injury: A tertiary care hospital experience by
AnisUzZaman, Muhammad Iqbal, FarhanZaheer, Rehan Abbas Khan, Khalid Ahsan Malik, Postoperative
complication recorded were wound infection 30.4%, wound dehiscence 6.3%, abdominal sepsis 3.8%.
In present study it was found that mortality rate was 16 percentage in compare to study by AnizZaman where it
was 10.1 percentage.
Hemorrhage leading to DIC and Shock are the most common cause of death worldwide in cases of penetrating
trauma. Amount of blood loss before presenting to hospital and blood loss during surgery accounts maximum.
First factor cannot be controlled that is blood loss before reaching to hospital but second factor can be controlled
by proper resuscitation and definite surgery. In cases damage control surgery may be required, where control of
bleeding is primary aim and definite surgery at later time. In emergency set up surgeries are carried out in night
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Present study
(n=25)
09
11
2
3
5 days
6-10 days
11-15days
16days
Percentage
36
44
8
12
80 percentage patients were discharged within 10 days. The cause of prolonged post operative stay was
pneumonia in 2 cases and wound related complication in 3 cases. Factors affecting post op stay are peritonitis
and contamination at ime of presentation, other comorbid condition like diabetes, IHD, Malnutrition which
impairs wound healing.
Average hospital stay in my study was found to be 8 days comparable to study by AnisUzZaman, Muhammad
Iqbal, FarhanZaheer, Rehan Abbas Khan, KhalidAhsan Malik.
Table 17:Outcome
Outcome
Survival
Death
Morbidity
Total
Present study
21
04
07
25
Percentage
84
16
28
100
Overall survival rate was 84 % with mortality 16 %. Early Morbidity was found in form of wound related
complications SSI and wound dehiscence, reasons for such complication appears to be emergency surgery in
case of category 3 and 4 where bilious and fecal peritonitis have set in at time of presentation. Other factors like
inadequate bowel preparation and no or minimal optimization of comorbid condition like diabetes,
malnutrition,IHD etc.
Late morbidity and sequel in form of incisional hernia and diaphragmatic hernia were found due to wound
related complications.
Morbidity rate in my study is 28 percentage was comparable to study by AnisUzZaman, where morbidity was
30.6 percentage including early and late complications .
I have observed mortality rate of 16% (n=04) and Persistent shock and hemorrhage (n=2,50%) is the most
common cause of death in my study. The reason was extensive hemorrhage leading to DIC and Shock. Other
causes were septicemia and Pneumonia. The average hospital stay in my study is 8 days which is comparable
with other studies. The above findings were comparable to study by AnisUzZaman where mortality was 10.2
and morbidity 30.6 percentage with average hospital stay 8 days. Out of 25 trauma patients 21 (86%) has
survived and shown good prognosis on follow ups.
6) Summary
In present study we have considered randomly selected 25 cases of penetrating thoracic and abdominal
trauma according to our inclusion and exclusion criteria. Study was conducted during period of 30
months (July 2012 to December 2014).
After filling details in proforma, master chart was prepared. A detailed analysis was done and various
observations were derived, discussed and concluded.
The penetrating thoracic and abdominal trauma is more common in age group 21-40 years (n=18,72%)
with male predominance (M:F:24:1) as they are economically productive, more active, and more liable to
undergo rage and homicidal attempts and sustain injuries.
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In present study injury pattern showed that 21(84%) cases were pure abdominal injuries, followed by
3(12%) cases of thoracic injuries and 01(04%) case was abdomino-thoracic. Abdominal injury
accounting for maximum number of cases (76%).
Homicidal injury abdomen (n=19,76%) is more common than Accidental injuries (n=4,16%) and Suicidal
injury (n=2,08%). Concluding that penetrating injury is most common form of homicidal injury.
22 (88%) patients presented with abdominal pain and 5(20%) patients had history of evisceration of
bowel,6 (24%) patients had vomiting,15(60%) patients had history of bleeding from local site, 13 (52%)
patients presented with abdominal distension, 6(24%) patients were in hypotension and 18 (76%) patients
had tachycardia at the time of presentation, 8 (32%) patients had associated chest pain and breathlessness
Abdominal pain ,tachycardia and abdominal distension is the most common clinical feature in all
abdominal trauma patients. Presence of these signs and symptoms warrants immediate attention (prompt
primary resuscitation and timely definitive treatment) in abdominal trauma.
In my study 6 (24%) patients presented with associated CLW, 1 patient had tendon rupture and 1 had
head injury. Representing defense wounds and post syncope injuries.
In my study 5(20%) patients had anemia on presentation which might be due to blood loss or pre-existing
condition. 1 had some psychiatric illness who presented with suicide and 2 patients had history of some
surgery in past.
Study showed that 18(72%) patients had single entry wound, 6(36%) patients had 2-5 entry wounds and 1
patient had more than 5 wounds on presentation. Suggesting dominance of single entry wound on
presentation. Study also showed 20(80%) patients had acute angle wound centring midline, 4(16%)
patients had direct right angle entry wound and 1(04%) patient had obtuse angle. This states that wound
impacted were most of the times towards center.
In present study injury pattern showed that 9(36%) cases had entry wound in umbilical region, followed
by right iliac, right lumbar and lateral chest with 4(16%) cases each. Lt iliac, lt lumbar, hypogastrium and
central chest showed least impact. Umbilical area involved the most.
In my study 6(24%) patients had jejunal injuries, followed by tranverse colon, Liver and Kidney 2(8%)
cases each. All thoracic injury were associated with lung parenchymal injuries as all of them were lateral
chest wall injuries. No cases were associated with major thoracic vessel and heart. Thus small bowel
being the most frequently involved organ in abdomen and lung parenchyma due to its site and vast area it
covers. Finding was consistent with other studies.
Most common peroperative finding was hemoperitoneum due to anterior abdominal wall injury or trivial
trauma to omentum which was treated by simple drainage and lavage, the second common finding was
jejunal perforation (single) treated by primary repair, then followed by multiple small bowel perforation
with mesentric involvement treated by resection anastamosis of affected segment. Then came in order
transverse colon, liver and kidney with similar incidences which were repaired primarily.
In case of thoracic injury out of 4 cases 3 were managed conservatively by ICD insertion and monitoring,
1 thoracotomy was done which showed internal mammary artery tear, which was ligated and ICD
insertion was done. Findings were similar to other studies where most of thoracic trauma is managed
conservatively by simple intercostal drainage.
In Post operative stay it was found that average drain output was 70ml/day for small bowel perforation
and patient was started oral feeding on POD 5, removal day of drain was averaging sixth day after
starting orally, for hemoperitoneum alone drainage average drain output 30ml/day, patient started oral
feeding on POD 3 and drain removed on 5th day, Liver parenchymal injury was associated with high
drain output averaging 100ml/day, oral feeds allowed from 2nd post op day and drain removal on 5th
day. Renal parenchymal injuries were associated with high drain output and patient started orally on 3rd
day.
Post operative recovery in this study was associated with good amount of complication rate of 28%
(n=7) and most of the complications were wound related, reasons for such complication appears to be
emergency surgery in case of category 3 and 4 where bilious and fecal peritonitis have set in at time of
presentation. Other factors like inadequate bowel preparation and no or minimal optimization of
comorbid condition like diabetes, malnutrition,IHD etc.
Post operative morbidity in this study was found in form of incisional hernia and diaphragmatic hernia
one case each. Incisional hernia was complication related to wound dehiscence and diaphragmantic
hernia was due to lack of diagnosis.
I have observed mortality rate of 16% (n=04) and Persistent shock and hemorrhage (n=2,50%) is the most
common cause of death in my study. The reason was extensive hemorrhage leading to DIC and Shock.
Other causes were septicemia and Pneumonia.
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The average hospital stay in my study is 8 days which is comparable with other studies. 80 percentage
patients were discharged within 10 days. The cause of prolonged post operative stay was pneumonia in 2
cases and wound related complication in 3 cases. Factors affecting post op stay are peritonitis and
contamination at ime of presentation, other comorbid condition like diabetes, IHD, Malnutrition which
impairs wound healing.
Out of 25 trauma patients 21 (86%) has survived and shown good prognosis on follow ups. These data
suggests that good outcome can be achieved if proper evaluation done and timely definitive treatment is
given to the trauma victims.
7) Conclusions
In present study I have concluded that penetrating trauma is common in young males between 20 to 40
years age group most commonly homicidal injury, they are economically productive, more active, and
more liable to undergo rage and homicidal attempts and sustain injuries.
Most common pattern of injury is abdominal, umbilical region most commonly involved and in thorax
lateral chest wall.
Most common presentation found to be pain, tachycardia and bleeding from local site followed by
vomiting, evisceration of bowel, breathlessness and hypotension.
Organ involved most commonly was jejunum and most common procedure done was drainage and lavage.
Almost all procedure and surgery were performed in emergency, many of them in middle of night when
there is lack of expertise and some facilities add up to the risk of more complication rates.
Wound complications were higher, reasons for such complication appears to be emergency surgery in case
of category 3 and 4 where bilious and fecal peritonitis have set in at time of presentation. Other factors like
inadequate bowel preparation and no or minimal optimization of comorbid condition like diabetes,
malnutrition, IHD etc.
So for good outcome thorough clinical assessment, expertise, primary resuscitation, timely definitive
treatment is of prime importance.
8) References
[1].
[2].
[3].
[4].
[5].
[6].
[7].
[8].
[9].
[10].
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[14].
[15].
[16].
[17].
[18].
[19].
[20].
[21].
[22].
[23].
[24].
[25].
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J.E. Pridgen and A.F. Heriff (1967) reviewed 776 cases of penetrating abdominal wounds1967 June; 165(6): 901907. PMCID:
PMC1617535.
Penetrating chest injuries: analysis of 99 cases by lk YAZICI, Alkn YAZICIOLU, Ertan AYDIN, Koray AYDODU, Sadi
KAYA, Nurettin KARAOLANOLU. Turk J Med Sci 2012; 42(6): 1082-1085
Penetrating Chest Trauma In North Of Jordan: A Prospective Study by M Khammash, F El Rabee published in The Internet Journal
of Thoracic and Cardiovascular Surgery Volume 8 Number 1 during the year 2005.
9) Acknowledgements
I wish to extend my heart felt gratitude and respect to my esteemed guide and mentor my P.G.TeacherDr.
Gunvant H. Rathod (M.S), Professor and Head of Department Of Surgery, B.J.Medical college and Civil
Hospital, Ahmedabad, who has been my unfailing source of inspiration, strength and moral support. I am highly
obliged to him who guided me throughout this endeavour. I am lucky enough to share a bit of his experience,
knowledge and enthusiasm.
I am greatly thankful to Dr. RakeshA.Makwana (M.S.), Dr. Ravi P. Gadani, and Dr. Rajesh K. Patel
Assistant Professor in department of General Surgery, B.J.Medical college and Civil Hospital, Ahmedabad.
In a deeply appreciated manner I acknowledge my thanks to the entire staff of library, B.J.Medicalcollege,
Ahmedabad, staff members of the dept.of surgery and my colleagues for their selfless help.
Last but not the least, it would be ingratitude, if I fail to thank all my patients, who form the actual skeleton of
this subject.
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